GLASGOW – When acute nonspecific symptoms might represent neuropsychiatric lupus, it is necessary to carefully review a patient's past medical history, because the presenting symptoms of systemic lupus erythematosus are manifold, may mimic other disorders, and can evolve over time, Dr. Hala Y. Sadik reported in a poster.
This is particularly the case when the onset is acute, as happened in a case treated by Dr. Sadik of the Academic Rheumatology Unit, University Hospital Aintree, Liverpool, England.
In August 2005, a 57-year-old woman presented with hypothermia, bradycardia, confusion, a low score on the Glasgow Coma Scale, and hyponatremia. The patient's plasma sodium level was low (120 mmol/L), as well as her plasma osmolality (235 mOsm/kg), while urinary sodium and osmolality levels were both high. A diagnosis of inappropriate antidiuretic hormone secretion was made, Dr. Sadik reported in a poster session at the annual meeting of the British Society for Rheumatology.
Initial management included fluid restriction and administration of double-strength normal saline, which normalized the plasma sodium level, reported Dr. Sadik. Initial MRI of the head raised the possibility of neurosarcoidosis, but serum angiotensin-converting enzyme levels and chest x-ray were normal. A repeat MRI with gadolinium suggested demyelinating disease or systemic lupus erythematosus. Immunology profile findings included positive antinuclear antibody (ANA) and double- stranded DNA antibody. Thrombocytopenia and lymphopenia also were present.
Upon review, her previous case records from another hospital revealed that she had been admitted in 1992 with a 2-week history of arthralgias, Raynaud's phenomenon, thrombocytopenia, lymphopenia, and positive ANA. A diagnosis of lupus had been considered at that time, and she was followed for several years as an outpatient, but ANA remained weakly positive and double-stranded DNA was persistently negative, so the diagnosis had been dismissed, Dr. Sadik wrote.
With improvements on the Glasgow Coma Scale during her current admission, it became apparent that the patient was profoundly depressed, so she was treated with mirtazapine.
After a diagnosis of neuropsychiatric lupus, the patient began treatment with intravenous methylprednisolone and cyclophosphamide. Significant improvements were seen in her disabling depression, and her hematologic parameters normalized.